MEDICARE: CASEY RYKO JESTROVICH CNIM, R. EEG T

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZE0600X	Electroneurodiagnostic Specialist/Technologist	99-187-0511	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VAD450M96159	OTHER	CO	ANTHEM BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1538635982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY RYKO JESTROVICH CNIM, R. EEG T

Provider Business Mailing Address
First Line	:	2318 HALL AVE
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81501-6234
Country	:	US
Telephone Number	:	303-886-6641
Fax Number	:

Provider Business Practice Location Address
First Line	:	2318 HALL AVE
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81501-6234
Country	:	US
Telephone Number	:	303-886-6641
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2018
Last Update Date	:	10/23/2018

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